Direct Deposit Form
Direct Deposit/Electronic Fund Transfer (EFT) Authorization Form For Reimbursement Accounts
Fax Completed Form to: 1-866-932-2567 You may also mail a completed form to: PayFlex Systems USA, Inc. PO Box 981158 El Paso, TX 79998-1158 Telephone: 1-888-879-1454
WAIT! Did you know that you can enroll in direct deposit online? Log in to your member website to get started. New Agreement
Change Account
Cancel Agreement
Authorization: By signing below, I hereby authorize PayFlex Systems USA, Inc. (PayFlex) to make electronic credit transactions to my financial institution listed below for reimbursement from my employer-sponsored reimbursement account. I authorize PayFlex to initiate debit entries, if necessary, for any credit entries made in error. I also authorize and request the bank listed below to accept any debit or credit entries by PayFlex to such account and to debit or credit same to such account. This authorization will remain in full force and effect until PayFlex has received written notification from me of its termination and in such time and in such manner as to afford a reasonable opportunity to act on it. To cancel or change this authorization, complete and sign this form indicating the required action and return it to the address listed above. In case of errors or if you have questions about your electronic transactions, call us at the number listed above or write us at the address listed above as soon as you can. If you think your bank statement is wrong or if you need more information about a transaction listed on your statement, we must hear from you no later than 60 days after the FIRST bank statement on which the problem or error appeared. Select One: Checking Account
Savings Account
Financial Institution Name
Branch
City
State
Transit/ABA Number (See example below)
ZIP Code
Account Number
Member Information Employer Name Member Name
Member Number (This may be your Social Security Number or employer assigned number)
This form must be completed, signed and dated to process. Member Signature
Date
For checking account, attach a voided check. For a savings account, attach a savings deposit slip.
PF-70 (11-15) HH – Purdue
Fax Completed Form to: 1-866-932-2567 You may also mail a completed form to: PayFlex Systems USA, Inc. PO Box 981158 El Paso, TX 79998-1158 Telephone: 1-888-879-1454
WAIT! Did you know that you can enroll in direct deposit online? Log in to your member website to get started. New Agreement
Change Account
Cancel Agreement
Authorization: By signing below, I hereby authorize PayFlex Systems USA, Inc. (PayFlex) to make electronic credit transactions to my financial institution listed below for reimbursement from my employer-sponsored reimbursement account. I authorize PayFlex to initiate debit entries, if necessary, for any credit entries made in error. I also authorize and request the bank listed below to accept any debit or credit entries by PayFlex to such account and to debit or credit same to such account. This authorization will remain in full force and effect until PayFlex has received written notification from me of its termination and in such time and in such manner as to afford a reasonable opportunity to act on it. To cancel or change this authorization, complete and sign this form indicating the required action and return it to the address listed above. In case of errors or if you have questions about your electronic transactions, call us at the number listed above or write us at the address listed above as soon as you can. If you think your bank statement is wrong or if you need more information about a transaction listed on your statement, we must hear from you no later than 60 days after the FIRST bank statement on which the problem or error appeared. Select One: Checking Account
Savings Account
Financial Institution Name
Branch
City
State
Transit/ABA Number (See example below)
ZIP Code
Account Number
Member Information Employer Name Member Name
Member Number (This may be your Social Security Number or employer assigned number)
This form must be completed, signed and dated to process. Member Signature
Date
For checking account, attach a voided check. For a savings account, attach a savings deposit slip.
PF-70 (11-15) HH – Purdue
